Abstract
Background:
COVID-19 pandemic brought adaptive changes in lifestyle with possible impact on the incidence of traumatic dental injuries.
Objective:
This study compared the presentation and pattern of traumatic dental injuries in children during the pre-COVID-19 and COVID-19 pandemic periods.
Materials and Methods:
This was a retrospective study done using clinical records of children aged 16 years and below who presented at the paediatric dental clinic of the University of Port Harcourt Teaching Hospital. Information such as demographics, aetiology, type of injuries, and dentition type were elicited from the 1284 clinical records from March 2019 to February 2021. Data were analysed and the level of significance was set at P ≤ 0.05.
Result:
One hundred (7.8%) patients presented with traumatic dental injuries (TDIs; 71 [8.5%] and 29 [6.5%] pre-pandemic [March 2019 to February 2020] and pandemic periods [March 2020 to February 2021], respectively) and their mean age was 7.0 (±4.2) years. The male-to-female ratio before and during the pandemic periods was 1.54:1 and 1.42:1, respectively. The commonest aetiology and type of TDI were falls 82 (82%) and injuries to tooth-supporting structures 45 (45%), respectively. There were no statistically significant differences in sex (P = 0.86), aetiology (P = 0.31), type of TDI (P = 0.16), and dentition affected (P = 0.97) between the pre-pandemic and pandemic periods but the difference in the age groups was significant (P = 0.02).
Conclusion:
The incidence of TDIs was higher in the pre-pandemic period. The younger age group had more dental injuries than the older ones at both periods. This may be due to difficulty in enforcing restrictions on young children even during COVID-19 restrictions.
Keywords: Children, COVID-19, dental injuries, trauma
Introduction
Traumatic dental injury (TDI) is a preventable but common occurrence among children and comprises 5% of all traumatic injuries requiring emergency hospital visits.[1] Though a prevalence that varied between 6% and 66% was observed by Zaleckiene et al.[2] in a review of epidemiological studies on TDI.[2] TDI affects not only the individual, but also the family members and the society hence it has become a public health challenge with far-reaching physical, psychosocial, and economic impacts.[3,4] Children and adolescents sustain dental trauma from unguarded playing on playgrounds, accidents at school, road traffic accidents, and sometimes violence.[3,4,5] Oro-facial features such as increased overjet, open bite, protrusive jaws, and lip incompetence have been shown to make a child more predisposed to sustaining dental trauma.[6] Other risk factors reported globally are the age, sex, non-impact absorbing environment, medical conditions, and socioeconomic backgrounds.[4,5,7]
TDI was reported to be more common among pre-school children with studies showing a wide variation in its prevalence.[7,8,9,10] This is due to their poor stability, passive reflexes, and indefinite movements,[9,10,11] however, in some other studies[12] it was reported to be commoner in children aged 6–12 years. Their presentation also differs with sex with global male-to-female ratio of 1.43:1,[13] suggesting that males are more likely to present with TDI than females. This finding has been given credence to by several studies.[10,12,14,15]
TDIs occur in both primary and permanent dentitions, and the incidence was reported to be higher in primary dentition,[10] though the study by Oredugba and Nzomiwu[12] and Ogordi et al.,[16] they reported a higher incidence in permanent dentition. Anterior teeth, especially the maxillary central and lateral incisors are the major teeth affected by TDI in both dentitions.[10,12] Generally, a single tooth is more commonly affected.[10,12,14] But, when dental injuries occur due to traumatic events involving sports and road traffic accidents, multiple teeth are often affected.
Dental trauma typically results in tooth displacement, fracture, or avulsion and may cause alteration in the physical appearance of the child leading to low confidence and poor self-esteem,[17] speech defects, challenges in mastication with serious consequences on the overall quality of life.[6,18] Trauma to the primary teeth may affect the unerupted permanent teeth (buds) and this may result in enamel hypoplasia, eruption anomalies and other forms of teeth malformations.[11,19]
COVID-19 was declared a global pandemic on March 11, 2020, by the World Health Organization, subsequently, there was a general decline in the number of emergency visits to hospitals on account of trauma as a result of restrictions and lockdowns.[20,21] It was, therefore, hypothesised that fewer children and adolescents reported to the clinic during the COVID pandemic as a result of the lockdown and restriction of movement. The government of Nigeria adopted and announced a nationwide lockdown on March 30, 2020, to curtail the pandemic with consequent restriction in both human and vehicular movements.
A number of studies have been carried out on TDI during COVID-19 pandemic,[22,23] however, there is paucity of literatures comparing the pattern of presentation pre-pandemic and pandemic. Therefore, the aim of this study was to determine the impact of COVID-19 pandemic on the pattern and presentation of traumatic dental injuries in a selected population of children in Port Harcourt, South-South Nigeria.
Materials and Methods
This was a retrospective review of clinical records of patients aged 16 years and below that presented pre-pandemic between March 2019 and February 2020 and a similar period during the pandemic from March 2020 to February 2021 at the paediatric dental clinic of the University of Port Harcourt Teaching Hospital, Port Harcourt, South-South Nigeria. Children aged 16 years and below, who presented with acute traumatic dental injuries without debilitating medical conditions were included in this review. Information on demographics such as the age as at the last birthday, sex, aetiology, type of injury, and dentition type were elicited from the clinical records. The aetiology was categorised as falls, fights, sports injuries, road traffic accidents, hit by an external object and collisions. The types of injury were categorised according to the new TDI classification of the World Health Organization; the International Classification of Diseases-11 (ICD-11).[24] The dentition type was either primary teeth, permanent teeth or not applicable when there were no teeth involved. Data were entered into a spreadsheet and analysed using IBM SPSS version 22. Chi-square test was used to determine the strength of association and the level of significance was set at P ≤ 0.05.
Results
A total of 838 (53.2%) and 446 (46.8%) patients were seen pre-COVID pandemic and COVID-19 pandemic periods, respectively, bringing the total number of patients seen to 1284. However, 100 (7.8%) of the cases were acute TDI, of which 71 (8.5%) subjects presented pre-COVID-19 pandemic, whereas 29 (6.5%) subjects were those who presented during the pandemic period. Sixty (60%) were males, the male-to-female ratio before the pandemic/total lockdown was 1.54:1, whereas male-to-female ratio was 1.42:1 in the pandemic period, the difference was not statistically significant (P = 0.86). Details are in Table 1.
Table 1.
The demographic characteristics and pattern of presentation of injury of teeth and supporting structures during the pre-COVID-19 and pandemic periods
| Variables | Pre-COVID-19 pandemic, n = 71 | COVID-19 pandemic, n = 29 | Total, n (%) | P value |
|---|---|---|---|---|
| Sex | ||||
| Males | 43 (60.6) | 17 (58.6) | 60 (60.0) | 0.86 |
| Females | 28 (39.4) | 12 (41.4) | 40 (40.0) | |
| Age groups (years) | ||||
| 1–4 | 20 (28.2) | 13 (44.8) | 33 (33.0) | 0.02a |
| 5–8 | 25 (35.2) | 3 (10.3) | 28 (28.0) | |
| 9–12 | 21 (29.6) | 7 (24.1) | 28 (28.0) | |
| 13–16 | 5 (7.6) | 6 (20.7) | 11 (11.0) | |
| Cause of TDI | ||||
| Falls | 57 (82.4) | 25 (86.2) | 82 (82.0) | 0.31 |
| RTA | 3 (4.2) | 2 (6.9) | 5 (5.0) | |
| Fights | 1 (1.4) | 0 | 1 (1.0) | |
| Collision | 4 (5.6) | 2 (6.9) | 6 (6.0) | |
| Hit by an object | 6 (8.5) | 0 | 6 (6.0) | |
| Type of TDI | ||||
| ISS | 35 (49.3) | 10 (34.5) | 45 (45.0) | 0.16 |
| Dental fractures | 29 (40.9) | 13 (44.8) | 42 (42.0) | |
| ISS and dental fracture | 2 (2.8) | 4 (13.8) | 6 (6.0) | |
| Soft tissue injury (laceration) | 5 (7.0) | 2 (6.9) | 7 (7.0) | |
| Type of dentition | ||||
| Primary | 25 (35.2) | 11 (37.9) | 36 (36.0) | 0.97 |
| Permanent | 41 (57.8) | 16 (55.2) | 57 (57.0) | |
| Not applicablea | 5 (7.0) | 2 (6.9) | 7 (7.0) | |
ISS: injury of supporting structures, IHT: injury of hard tissues; RTA: road traffic accidents, ST: soft tissue (laceration)
aIf teeth were not involved.
The 1–4 year age group were the majority (33%), whereas the 13–16 year age group were the least (11%) in both the pre-pandemic and the pandemic periods. And the difference between the age groups in both the pre-pandemic and post-pandemic was statistically significant (P = 0.02). The commonest cause of TDI was falls (82%) in both periods and the differences between the causes of TDI was not statistically significant (P = 0.31). Details are in Table 1.
Thirteen percent of them had multiple TDIs, 6% had both injuries of hard dental tissues (fractures) and injury of tooth-supporting structures [Table 1]. When the TDIs were categorised, injury of tooth-supporting structures was the commonest injury (45%) and this observation was also seen during the pre-pandemic period where injury of tooth-supporting structures was 49.3%, whereas injury of hard dental tissue (dental fractures [44.8%]) were commoner during the pandemic period [Figure 1]. However, there was no statistically significant difference between the pre- and pandemic periods (P = 0.16). The permanent dentition was the commonly affected dentition type in both periods and the difference between the periods was not statistically significant. Details are in Table 1. The more serious tooth-supporting injuries (TSI) occurred more commonly during the pandemic period. Intrusion was the commonest type of TSI. Details are in Figure 2. The enamel–dentine fractures of permanent tooth were more common in the pre-pandemic period whereas all the primary tooth fractures (enamel–dentine) occurred in the pandemic period. See Figure 3 for details.
Figure 1.
The distribution of traumatic dental injuries among the children pre-COVID-19 pandemic and pandemic periods. Lat Luxation: lateral luxation
Figure 2.
The distribution of tooth-supporting injuries among the subjects during the pre-COVID pandemic and pandemic periods
Figure 3.
The distribution of dental fractures among the subjects during the pre-COVID pandemic and pandemic periods
When the gender differences in both pre and pandemic periods were assessed there were no statistically significant differences in the types of injuries, aetiology, and dentition type, however, there was a statistical gender difference (P = 0.03) in the age groups in the pandemic period. Other details are depicted in Table 2.
Table 2.
Gender differences in the pre-COVID pandemic and pandemic periods
| Pattern of TDI | Pre-COVID-19 pandemic | COVID-19 pandemic | ||
|---|---|---|---|---|
| Males, n (%) | Females, n (%) | Males, n (%) | Females, n (%) | |
| Age groups (years) | ||||
| 1–4 | 13 (30.2) | 7 (25.0) | 10 (58.8) | 3 (25.0) |
| 5–8 | 11 (25.6) | 14 (50.0) | 0 (0) | 3 (25.0) |
| 9–12 | 16 (37.2) | 5 (17.9) | 5 (9.4) | 2 (16.7) |
| 13–16 | 3 (7.0) | 2 (7.1); P = 0.15 | 2 (11.8) | 4 (33.3); P = 0.03* |
| Cause of TDI | ||||
| Falls | 34 (79.1) | 23 (82.2) | 16 (94.1) | 9 (75.0) |
| RTA | 2 (4.7) | 1 (3.6) | 0 | 2 (16.7) |
| Fights | 1 (2.3) | 0 | 0 (0) | 0 (0) |
| Collision | 2 (4.7) | 2 (7.1) | 1 (5.9) | 1 (8.3) |
| Hit by an object | 4 (9.3) | 2 (7.1); P = 0.67 | 0 | 0; P = 0.14 |
| Type of TDI | ||||
| ISS | 21 (48.8) | 14 (50) | 7 (41.2) | 3 (25.0) |
| IHT/dental fractures | 18 (41.9) | 11 (39.3) | 7 (41.2) | 6 (50.0) |
| Both | 1 (2.3) | 1 (3.6) | 2 (11.8) | 2 (16.7) |
| Laceration | 3 (7.0) | 2 (7.2); P = 0.99 | 1 (5.9) | 1 (8.3); P = 0.84 |
| Type of dentition | ||||
| Primary | 14 (32.6) | 11 (39.3) | 9 (52.9) | 2 (16.7) |
| Permanent | 26 (60.5) | 15 (53.6) | 7 (41.2) | 9 (75.0) |
| Not applicable | 3 (7) | 2 (7.1); P = 0.84 | 1 (5.9) | 1 (8.3); P = 0.12 |
ISS: injury of supporting structures, IHT: injury of hard tissues, RTA: road traffic accidents, ST: soft tissue (laceration)
*p< 0.05 is statistically significant
The pattern of presentation of the injuries during both periods was assessed according to the age groups and there was a statistically significant difference in the pandemic period (P = 0.03) [Table 3].
Table 3.
The association of age and the types of injuries in both the pre-COVID pandemic and pandemic periods
| Period under study | Age group (years) | ISS | IHT | ISS and IHT | ST |
|---|---|---|---|---|---|
| Pre-pandemic | 1–4 | 10 (50) | 6 (30) | 1 (5) | 3 (15) |
| 5–8 | 16 (64) | 8 (32) | 0 | 1 (4) | |
| 9–12 | 9 (42.9) | 10 (47.6) | 1 (4.8) | 1 (4.8) | |
| 13–16 | 0 | 5 (100) | 0 | 0 | |
| Pa = 0.08 | |||||
| Pandemic | 1–4 | 7 (53.8) | 2 (15.4) | 2 (15.4) | 2 (15.4) |
| 5–8 | 0 | 3 (100) | 0 | 0 | |
| 9–12 | 1 (14.3) | 6 (85.7) | 0 | 0 | |
| 13–16 | 2 (33.3) | 2 (33.3) | 2 (33.3) | 0 | |
| Pa,* = 0.03 |
ISS: injury of supporting structures, IHT: injury of hard tissues, ISS and IHT: combination of ISS and IHT, ST: soft tissue (laceration), TSI: injury of tooth-supporting structures
aFisher’s exact; *P<0.05.
Discussion
The COVID-19 pandemic and its consequent restriction that affected all spheres of life; school, social activities, and general movements led to a reduction in patients’ attendance to the clinic by 46.8% in the present study. There was also a decrease in incidence of TDI from 8.5% in the pre-pandemic period to 6.5% in the pandemic period. These findings are expected as a consequence of the restrictions in activities during the partial or total lockdown period. This decrease of 23.5% of the incidence (i.e., 8.5% pre-pandemic to 6.5% pandemic) presented in the clinic is similar to the 26.1% reported by Guo et al.[25] but lower than the 68.3% of Yang et al.[26] There were no statistically significant changes in the pattern or presentation of dental injuries in the present study except that which was observed in the age groups.
There was a significant difference in the age groups, with the 1–4 years being more the commonly affected age group in the pandemic group. On the other hand, the 5–8-year-old age groups were more commonly affected pre-pandemic. This may be because these age groups are the younger age groups who play more often than the other age groups. There was a consequent reduction in incidence of trauma in these age groups (i.e., 1–4 years and 5–8 years) because there was restriction in their activities as a result of the pandemic. The finding in this study corroborates the reports by Guo et al.[25] and Yang et al.[26] in China where they reported that there were more preschoolers with TDIs in their studies compared to other age groups during the pandemic. However, the most commonly affected group pre-pandemic corroborates what was reported by Oredugba and Nzomiwu.[12]
The gender presentation was 1.54:1 and 1.42:1 male-to-female ratio before the pandemic and during the pandemic periods, respectively. There were no statistically significant differences between the males and females in both periods. This agrees with reports on male preponderance in most studies[10,12,14,15,26] and which has been attributed to rigorous and/or energetic activities in males.
There was no statistically significant difference in aetiology of trauma between the periods, however, falls were the commonest aetiology in both periods but were less in the pandemic period. Falls are known to occur more commonly in early childhood and take place more commonly in homes than in playgrounds or school environments.[10,12,14,18] This may be because parents/caregivers were at home with the children due to the lockdown and would monitor the types of activities engaged in by the children in the homes during the pandemic period. One would expect significant reduction of road traffic accidents (RTAs), during the pandemic period as a result of lockdown, but according to previous reports,[12,16] RTAs were not major aetiological factors in TDIs among children. However, there was an increase in RTAs in the pandemic period in this present study.
Injuries to tooth-supporting structures were the most common injury, though dental fractures occurred more frequently during the pandemic period. This contradicts previous reports[12,14,16] where dental fractures (enamel–dentine) were the commonest presentation. In this study, children older than 4 years old were about twice the number of those that were 4 years and below. The permanent dentition was more affected by TDI and this agrees with previous reports in Nigeria.[12,16] This could explain why the permanent dentition was more affected. Nevertheless, there were no statistically significant differences in both periods in the dentitions affected and type of injury. Among the dental fractures, the enamel–dentine fractures were the commonest presentation in both periods. This finding agrees with previous reports.[10,12,14,16]
In conclusion, the pattern and presentation of the traumatic dental injuries were similar in both periods studied, though there were fewer injuries during the pandemic period. There were statistically significant differences in the age groups especially during the pandemic.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
- 1.Andersson L. Epidemiology of trauamatic dental injuries. J Endod. 2013;39:S2–5. doi: 10.1016/j.joen.2012.11.021. [DOI] [PubMed] [Google Scholar]
- 2.Zaleckiene V, Peciuliene V, Brukiene V, Drukteinis S. Traumatic dental injuries: Etiology, prevalence and possible outcomes. Stomatologija. 2014;16:7–14. [PubMed] [Google Scholar]
- 3.Eigbobo JO, Nzomiwu CL, Etim SS, Amobi EO. The care of traumatic dental injuries in primary schools in Southern Nigeria. Eur J Paediatr Dent. 2015;16:197–200. [PubMed] [Google Scholar]
- 4.Eigbobo JO, Nzomiwu CL, Amobi EO, Etim SS. The standards of playgrounds and safety measures in prevention of traumatic dental injuries in Nigerian primary schools. J West Afr Coll Surg. 2014;4:79–96. [PMC free article] [PubMed] [Google Scholar]
- 5.Gendor U. Aetiology and risk factors to traumatic dental injuries—A review of the literature. Dent Traumatol. 2009;25:31. doi: 10.1111/j.1600-9657.2008.00694.x. [DOI] [PubMed] [Google Scholar]
- 6.Garg K, Kalra N, Tyagi R, Khatri A, Panwar G. An appraisal of the prevalence and attributes of traumatic dental injuries in the permanent anterior teeth among 7–14-year-old school children of North East Delhi. Contemp Clin Dent. 2017;8:218–24. doi: 10.4103/ccd.ccd_133_17. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Lam R. Epidemiology and outcomes of traumatic dental injuries: A review of the literature. Aust Dent J. 2016;61:4–20. doi: 10.1111/adj.12395. [DOI] [PubMed] [Google Scholar]
- 8.Ain TS, Telgi RL, Sultan S, Tangade P, Telgi CR, Tirth A, et al. Prevalence of traumatic dental injuries to anterior teeth of 12-year-old school children in Kashmir. Arch Trauma Res. 2016;23:e24596 doi: 10.5812/atr.24596. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Bharath KP. The reverberations of traumatized primary dentition: A practitioner’s perspective. J Contemp Dent Pract. 2011;12:511–5. [PubMed] [Google Scholar]
- 10.Eigbobo JO, Etim SS. The pattern of traumatic dental injuries in children in a tertiary health care facility in Nigeria. J Int Dent Med Res. 2016;9:33–8. [Google Scholar]
- 11.Fontenele M, Macedo M, Reboucas P, Silva PG, Lins de Sousa D, Araujo de Sousa RB, et al. Sequelae in primary teeth after traumatic injury. Braz Dent Sci. 2017;20:70–5. [Google Scholar]
- 12.Oredugba FA, Nzomiwu CL. Causes and pattern of traumatic dental injuries in children presenting for care at a tertiary health centre. J Int Dent Med Res. 2015;8:40–5. [Google Scholar]
- 13.Petti S, Gendor U, Andersson L. World traumatic dental injury prevalence and incidence. A meta analysis—One billion living people had traumatic dental injuries. Dent Traumatol. 2018;34:71–86. doi: 10.1111/edt.12389. [DOI] [PubMed] [Google Scholar]
- 14.Rajab LD. Traumatic dental injuries in children presenting for treatment at the Department of Pediatric Dentistry, Faculty of Dentistry, University of Jordan, 1997–2000. Dent Traumatol. 2003;19:6–11. doi: 10.1034/j.1600-9657.2003.00131.x. [DOI] [PubMed] [Google Scholar]
- 15.Otuyemi OD, Sofowora CA. Traumatic anterior dental injuries in selected rural primary school children in Ile-Ife, Nigeria. Nig Dent J. 1991;10:20–5. [Google Scholar]
- 16.Ogordi PU, Ize-Iyamu I. A ten year audit of traumatic dental injuries in children in a tertiary hospital in Southern Nigeria. Nig J Dent Res. 2020;5:177–184. [Google Scholar]
- 17.Abanto J, Tello G, Bonini GC, Oliveira LB, Murakami C, Bonecker M. Impact of traumatic dental injuries and malocclusions on quality of life of preschool children: A population based study. Int J Pediatr Dent. 2015;25:18–28. doi: 10.1111/ipd.12092. [DOI] [PubMed] [Google Scholar]
- 18.Siqueira MB, Gomes MC, Oliveira AC, Martins CC, Granville-Garcia AF, Paiva SM. Predisposing factors for traumatic dental injury in primary teeth and seeking of post-trauma care. Braz Dent J. 2013;24:647–54. doi: 10.1590/0103-6440201302352. [DOI] [PubMed] [Google Scholar]
- 19.Ranka M, Dhaliwal H, Albadri S, Brown C. Trauma to the primary dentition and its sequelae. Dent Update. 2013;40:534–6, 539. doi: 10.12968/denu.2013.40.7.534. [DOI] [PubMed] [Google Scholar]
- 20.Cai J, Sun W, Huang J, Gamber M, Wu J, He G. Indirect virus transmission in cluster of COVID-19 cases, Wenzhou, China, 2020. Emerg Infect Dis. 2020;26:1343–5. doi: 10.3201/eid2606.200412. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Ibrahim RL, Ajide KB, Julius OO. Easing of lockdown measures in Nigeria: Implication for the healthcare system. Health Policy Technol. 2020;9:399–404. doi: 10.1016/j.hlpt.2020.09.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Woolley J, Djemal S. Traumatic dental injuries during COVID-19 pandemic. Prim Dent J. 2021;10:28–32. doi: 10.1177/2050168420980994. [DOI] [PubMed] [Google Scholar]
- 23.Almeida FV, Costa VPP, Schuch HS, Geottems ML. Prevention and management of dental trauma in primary teeth in the context of the COVID-19: A critical literature review. Pesqui Bras Odontopediatria Clin Integr. 2021;21:e210077. [Google Scholar]
- 24.Petti S, Andreasen JO, Glendor U, Andersson L. NA0D—The new traumatic dental injury classification of the World Health Organization. Dental Traumatol. 2022;38:170–4. doi: 10.1111/edt.12753. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Guo H, Zhou Y, Liu X, Tan J. The impact of the COVID-19 epidemic on the utilization of emergency dental services. J Dent Sci. 2020;15:564–7. doi: 10.1016/j.jds.2020.02.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Yang Y, Zhang W, Xie L, Li ZB, Li Z. Characteristics changes of traumatic dental injuries in a teaching hospital of Wuhan under transmission control measures during the COVID-19 epidemic. Dental Traumatol. 2020;36:584–58. doi: 10.1111/edt.12589. [DOI] [PMC free article] [PubMed] [Google Scholar]